There are over a thousand different psychotherapy techniques, some being minor variations, while others are based on very different conceptions of psychology, ethics (how to live), or techniques. Most involve one-to-one sessions, between client and therapist, but some are conducted with groups,[1] including families.

Psychotherapists may be mental health professionals such as psychiatrists, psychologists, clinical social workers, marriage and family therapists, or professional counselors. Psychotherapists may also come from a variety of other backgrounds, and depending on the jurisdiction may be legally regulated, voluntarily regulated or unregulated (and the term itself may be protected or not).

The American Psychological Association adopted a resolution on the effectiveness of psychotherapy in 2012 based on a definition developed by John C. Norcross: “Psychotherapy is the informed and intentional application of clinical methods and interpersonal stances derived from established psychological principles for the purpose of assisting people to modify their behaviors, cognitions, emotions, and/or other personal characteristics in directions that the participants deem desirable”.[3][4] Influential editions of a work by psychiatrist Jerome Frank defined psychotherapy as a healing relationship using socially authorized methods in a series of contacts primarily involving words, acts and rituals—regarded as forms of persuasion and rhetoric.[5]

Some definitions of counseling overlap with psychotherapy (particularly in non-directive client-centered approaches), or counseling may refer to guidance for everyday problems in specific areas, typically for shorter durations with a less medical or ‘professional’ focus.[6]Somatotherapy refers to the use of physical changes as injuries and illnesses, and sociotherapy to the use of a person’s social environment to effect therapeutic change.[7] Psychotherapy may address spirituality as a significant part of someone’s mental / psychological life, and some forms are derived from spiritual philosophies, but practices based on treating the spiritual as a separate dimension are not necessarily considered as traditional or ‘legitimate’ forms of psychotherapy.[8]

Psychotherapy is often dubbed as a “talking therapy”, particularly for a general audience,[10] though not all forms of psychotherapy rely on verbal communication.[11] Children or adults who do not engage in verbal communication (or not in the usual way) are not excluded from psychotherapy; indeed some types are designed for such cases.

Delivery

It has not been established whether the effectiveness of psychotherapy administered online, over video chat for instance, is comparable to that delivered within in-person meetings:[13]Clear, consistent trends from empirical research are lacking regarding the efficacy of online therapy – Australian Counselling Association.[14]

The Victoria Government’s Health Agency has awarded no mental health app with scores greater than 3 stars out of 5 for effectiveness.[15] One reason for this is that online Cognitive Behavioural Therapy programs have poor “adherence” compared to face-to-face programs. That means that many users do not “stick to” the program as prescribed. They may uninstall the app or skip days, for instance.[16]

Treatments duration

Experts suggests that those who have had two depressive episodes in recent years, or three episodes over their life, have to get treated on an ongoing basis to prevent recurrent depression:[17]At least 60% of individuals who have had one depressive episode will have another, 70% of individuals who have had two depressive episodes will have a third, and 90% of individuals with three episodes will have a fourth episode. – American Psychological Association.[18]

Regulation

Psychotherapists traditionally may be: mental health professionals like psychologists and psychiatrists; professionals from other backgrounds (family therapists, social workers, nurses, etc.) who have trained in a specific psychotherapy; or (in some cases) academic or scientifically-trained professionals.Psychiatrists are trained first as physicians, and—as such—they may prescribe prescription medication; and specialist psychiatric training begins after medical school in psychiatric residencies: however, their specialty is in mental disorders or forms of mental illness. Clinical psychologists have specialist doctoral degrees in psychology with some clinical and research components. Other clinical practitioners, social workers, mental health counselors, pastoral counselors, and nurses with a specialization in mental health, also often conduct psychotherapy. Many of the wide variety of psychotherapy training programs and institutional settings are multi-professional. In most countries, psychotherapy training are all at a post-graduate level, often at a master’s degree (or doctoral) level, over a 4-year period, with significant supervised practice and clinical placements. Such professionals doing specialized psychotherapeutic work also require a program of continuing professional education after basic professional training.

There is a 2013 listing of the extensive professional competencies of a European psychotherapist, developed by the European Association of Psychotherapy (EAP).[19]

As sensitive and deeply personal topics are often discussed during psychotherapy, therapists are expected, and usually legally bound, to respect client or patient confidentiality. The critical importance of client confidentiality—and the limited circumstances in which it may need to be broken for the protection of clients or others—is enshrined in the regulatory psychotherapeutic organizations’ codes of ethical practice.[20] Examples of when it is typically accepted to break confidentiality include when the therapist has knowledge that a child or elder is being physically abused; when there is a direct, clear and imminent threat of serious physical harm to self or to a specific individual.

Europe

As of 2015, there are still a lot of variations between different European countries about the regulation and delivery of psychotherapy. Several countries have no regulation of the practice or no protection of the title. Some have a system of voluntary registration, with independent professional organizations, while other countries attempt to restrict the practice of psychotherapy to ‘mental health professionals’ (psychologists and psychiatrists) with state-certified training. The titles that are protected also vary.[21] The European Association for Psychotherapy (EAP) established the 1990 Strasbourg Declaration on Psychotherapy, which is dedicated to establishing an independent profession of psychotherapy in Europe, with pan-European standards.[22] The EAP has already made significant contacts with the European Union & European Commission towards this end.

Given that the European Union has a primary policy about the free movement of labor within Europe, European legislation can overrule national regulations that are, in essence, forms of restrictive practices.

In Germany, the practice of psychotherapy for adults is restricted to qualified psychologists and physicians (including psychiatrists) who have completed several years of specialist practical training and certification in psychotherapy. As psychoanalysis, psychodynamic therapy, and cognitive behavioral therapy meet the requirements of German health insurance companies, mental health professionals regularly opt for one of these three specializations in their postgraduate training. For psychologists, this includes three years of full-time practical training (4.200 hours), encompassing a year-long internship at an accredited psychiatric institution, six months of clinical work at an outpatient facility, 600 hours of supervised psychotherapy in an outpatient setting, and at least 600 hours of theoretical seminars.[23]Social workers may complete the specialist training for child and teenage clients.[24] Similarly in Italy, the practice of psychotherapy is restricted to graduates in psychology or medicine who have completed four years of recognised specialist training.[25][26] Sweden has a similar restriction on the title “psychotherapist”, which may only be used by professionals who have gone through a post-graduate training in psychotherapy and then applied for a licence, issued by the National Board of Health and Welfare.[27]

Legislation in France restricts the use of the title “psychotherapist” to professionals on the National Register of Psychotherapists,[28] which requires a training in clinical psychopathology and a period of internship which is only open to physicians or titulars of a master’s degree in psychology or psychoanalysis.[citation needed]

United States

In some states, counselors or therapists must be licensed to use certain words and titles on self-identification or advertising. In some other states, the restrictions on practice are more closely associated with the charging of fees. Licensing and regulation are performed by various states. Presentation of practice as licensed, but without such a license, is generally illegal.[34] Without a license, for example, a practitioner cannot bill insurance companies.[35] Information about state licensure is provided by the American Psychological Association.[36]

In addition to state laws, the American Psychological Association requires its members to adhere to its published Ethical Principles of Psychologists and Code of Conduct.[37] The American Board of Professional Psychology examines and certifies “psychologists who demonstrate competence in approved specialty areas in professional psychology”.[38]

History

Psychotherapy can be said to have been practiced through the ages, as medics, philosophers, spiritual practitioners and people in general used psychological methods to heal others.[39][40]

In the Western tradition, by the 19th century, a moral treatment movement (then meaning morale or mental) developed based on non-invasive non-restraint therapeutic methods.[41] Another influential movement was started by Franz Mesmer (1734–1815) and his student Armand-Marie-Jacques de Chastenet, Marquis of Puységur (1751–1825). Called Mesmerism or animal magnetism, it would have a strong influence on the rise of dynamic psychology and psychiatry as well as theories about hypnosis.[42][43] In 1853 Walter Cooper Dendy introduced the term “psycho-therapeia” regarding how physicians might influence the mental states of sufferers and thus their bodily ailments, for example by creating opposing emotions to promote mental balance.[44][45]Daniel Hack Tuke cited the term and wrote about “psycho-therapeutics” in 1872, in which he also proposed making a science of animal magnetism.[46][47]Hippolyte Bernheim and colleagues in the “Nancy School” developed the concept of “psychotherapy” in the sense of using the mind to heal the body through hypnotism, yet further.[46] Charles Lloyd Tuckey’s 1889 work, Psycho-therapeutics, or Treatment by Hypnotism and Suggestion popularized the work of the Nancy School in English.[46][48] Also in 1889 a clinic used the word in its title for the first time, when Frederik van Eeden and Albert Willem in Amsterdam renamed theirs “Clinique de Psycho-thérapeutique Suggestive” after visiting Nancy.[46] During this time, travelling stage hypnosis became popular, and such activities added to the scientific controversies around the use of hypnosis in medicine.[46] Also in 1892, at the second congress of experimental psychology, van Eeden attempted to take the credit for the term psychotherapy and to distance the term from hypnosis.[46] In 1896, the German journal Zeitschrift für Hypnotismus, Suggestionstherapie, Suggestionslehre und verwandte psychologische Forschungen changed its name to Zeitschrift für Hypnotismus, Psychotherapie sowie andere psychophysiologische und psychopathologische Forschungen, which is probably the first journal to use the term.[46] Thus psychotherapy initially meant “the treatment of disease by psychic or hypnotic influence, or by suggestion”.[2]

Freud, seated left of picture with Jung seated at the right of the picture. 1909

During the 1950s, Albert Ellis originated rational emotive behavior therapy (REBT). Independently a few years later, psychiatrist Aaron T. Beck developed a form of psychotherapy known as cognitive therapy. Both of these included relatively short, structured and present-focused techniques aimed at identifying and changing a person’s beliefs, appraisals and reaction-patterns, by contrast with the more long-lasting insight-based approach of psychodynamic or humanistic therapies. Beck’s approach used primarily the socratic method, and links have been drawn between ancient stoic philosophy and these cognitive therapies.[50]

Cognitive and behavioral therapy approaches were increasingly combined and grouped under the umbrella term cognitive behavioral therapy (CBT) in the 1970s. Many approaches within CBT are oriented towards active/directive yet collaborative empiricism (a form of reality-testing), and assessing and modifying core beliefs and dysfunctional schemas. These approaches gained widespread acceptance as a primary treatment for numerous disorders. A “third wave” of cognitive and behavioral therapies developed, including acceptance and commitment therapy and dialectical behavior therapy, which expanded the concepts to other disorders and/or added novel components and mindfulness exercises. However the “third wave” concept has been criticized as not essentially different from other therapies and having roots in earlier ones as well.[51] Counseling methods developed include solution-focused therapy and systemic coaching.

Types

Overview

There are hundreds of psychotherapy approaches or schools of thought. By 1980 there were more than 250;[53] by 1996 more than 450;[54] and at the start of the 21st century there were over a thousand different named psychotherapies—some being minor variations while others are based on very different conceptions of psychology, ethics (how to live) or technique.[55][56] In practice therapy is often not of one pure type but draws from a number of perspectives and schools—known as an integrative or eclectic approach.[57][58] The importance of the therapeutic relationship, also known as therapeutic alliance, between client and therapist is often regarded as crucial to psychotherapy. Common factors theory addresses this and other core aspects thought to be responsible for effective psychotherapy.
Sigmund Freud (1856–1939), a Viennese neurologist who studied with Jean-Martin Charcot in 1885, is often considered the father of modern psychotherapy. His methods included analyzing dreams for important insights that layout of awareness of the dreamer. Other major elements of his methods, which changed throughout the years, included identification of childhood sexuality, the role of anxiety as a manifestation of inner conflict, the differentiation of parts of the psyche (id, ego, superego), transference and countertransference (the patient’s projections onto the therapist, and the therapist’s emotional responses to that). Some of his concepts were too broad to be amenable to empirical testing and invalidation, and he was critiqued for this by Jaspers. Numerous major figures elaborated and refined Freud’s therapeutic techniques including Melanie Klein, Donald Winnicott, and others. Since the 1960s, however, the use of Freudian-based analysis for the treatment of mental disorders has declined substantially. Different types of psychotherapy have been created along with the advent of clinical trials to test them scientifically. These incorporate subjective treatments (after Beck), behavioral treatments (after Skinner and Wolpe) and additional time-constrained and centered structures, for example, interpersonal psychotherapy. In youth issue and in schizophrenia, the systems of family treatment hold esteem. A portion of the thoughts emerging from therapy are presently pervasive and some are a piece of the armamentarium of ordinary clinical practice. They are not just medications, they additionally help to understand complex conduct.

Psychotherapies are categorized in several different ways. A distinction can be made between those based on a medical model and those based on a humanistic model. In the medical model, the client is seen as unwell and the therapist employs their skill to help the client back to health. The extensive use of the DSM-IV, the diagnostic and statistical manual of mental disorders in the United States is an example of a medically exclusive model. The humanistic or non-medical model in contrast strives to depathologise the human condition. The therapist attempts to create a relational environment conducive to experiential learning and help build the client’s confidence in their own natural process resulting in a deeper understanding of themselves. The therapist may see themselves as a facilitator/helper.

Therapies are sometimes classified according to their duration; a small number of sessions over a few weeks or months may be classified as brief therapy (or short-term therapy), others, where regular sessions take place for years, may be classified as long-term.

Some practitioners distinguish between more “uncovering” (or “depth“) approaches and more “supportive” psychotherapy. Uncovering psychotherapy emphasizes facilitating the client’s insight into the roots of their difficulties. The best-known example is classical psychoanalysis. Supportive psychotherapy by contrast stresses strengthening the client’s coping mechanisms and often providing encouragement and advice, as well as reality-testing and limit-setting where necessary. Depending on the client’s issues and situation, a more supportive or more uncovering approach may be optimal.[59]

Most forms of psychotherapy use spoken conversation. Some also use various other forms of communication such as the written word, artwork, drama, narrative story or music. Psychotherapy with children and their parents often involves play, dramatization (i.e. role-play), and drawing, with a co-constructed narrative from these non-verbal and displaced modes of interacting.[60]

There are also different formats for delivering some therapies, as well as the usual face to face: for example via telephone or via online interaction. There have also been developments in computer-assisted therapy, such as virtual reality therapy for behavioral exposure, multimedia programs to each cognitive techniques, and handheld devices for improved monitoring or putting ideas into practice.[61][62]

Humanistic

These psychotherapies, also known as “experiential“, are based on humanistic psychology and emerged in reaction to both behaviorism and psychoanalysis, being dubbed the “third force”. They are primarily concerned with the human development and needs of the individual, with an emphasis on subjective meaning, a rejection of determinism, and a concern for positive growth rather than pathology.[63] Some posit an inherent human capacity to maximize potential, “the self-actualizing tendency”; the task of therapy is to create a relational environment where this tendency might flourish.[64] Humanistic psychology can, in turn, be rooted in existentialism—the belief that human beings can only find meaning by creating it. This is the goal of existential therapy. Existential therapy is in turn philosophically associated with phenomenology.[65]

Person-centered therapy, also known as client-centered, focuses on the therapist showing openness, empathy and “unconditional positive regard”, to help clients express and develop their own self.[66]

Gestalt therapy, originally called “concentration therapy”, is an existential/experiential form that facilitates awareness in the various contexts of life, by moving from talking about relatively remote situations to action and direct current experience. Derived from various influences, including an overhaul of psychoanalysis, it stands on top of essentially four load-bearing theoretical walls: phenomenological method, dialogical relationship, field-theoretical strategies, and experimental freedom.[67]

A briefer form of humanistic therapy is the human givens approach, introduced in 1998/9.[68] It is a solution-focused intervention based on identifying emotional needs—such as for security, autonomy and social connection—and using various educational and psychological methods to help people meet those needs more fully or appropriately.[69][70][71][72]

Cognitive-behavioral

Behavior therapies use behavioral techniques, including applied behavior analysis (also known as behavior modification), to change maladaptive patterns of behavior to improve emotional responses, cognitions, and interactions with others. Functional analytic psychotherapy is one form of this approach. By nature, behavioral therapies are empirical (data-driven), contextual (focused on the environment and context), functional (interested in the effect or consequence a behavior ultimately has), probabilistic (viewing behavior as statistically predictable), monistic (rejecting mind-body dualism and treating the person as a unit), and relational (analyzing bidirectional interactions).[77]

Cognitive therapy focuses directly on changing the thoughts, in order to improve the emotions and behaviors.

Cognitive behavioral therapy attempts to combine the above two approaches, focused on the construction and reconstruction of people’s cognitions, emotions and behaviors. Generally in CBT, the therapist, through a wide array of modalities, helps clients assess, recognize and deal with problematic and dysfunctional ways of thinking, emoting and behaving.

Interpersonal psychotherapy (IPT) is a relatively brief form of psychotherapy (deriving from both CBT and psychodynamic approaches) that has been increasingly studied and endorsed by guidelines for some conditions. It focuses on the links between mood and social circumstances, helping to build social skills and social support.[78] It aims to foster adaptation to current interpersonal roles and situations.

The term group therapy was first used around 1920 by Jacob L. Moreno, whose main contribution was the development of psychodrama, in which groups were used as both cast and audience for the exploration of individual problems by reenactment under the direction of the leader. The more analytic and exploratory use of groups in both hospital and out-patient settings was pioneered by a few European psychoanalysts who emigrated to the US, such as Paul Schilder, who treated severely neurotic and mildly psychotic out-patients in small groups at Bellevue Hospital, New York. The power of groups was most influentially demonstrated in Britain during the Second World War, when several psychoanalysts and psychiatrists proved the value of group methods for officer selection in the War Office Selection Boards. A chance to run an Army psychiatric unit on group lines was then given to several of these pioneers, notably Wilfred Bion and Rickman, followed by S. H. Foulkes, Main, and Bridger. The Northfield Hospital in Birmingham gave its name to what came to be called the two “Northfield Experiments”, which provided the impetus for the development since the war of both social therapy, that is, the therapeutic community movement, and the use of small groups for the treatment of neurotic and personality disorders. Today group therapy is used in clinical settings and in private practice settings.[80]

Expressive

Expressive therapy is any form of therapy that utilizes artistic expression as its core means of treating clients. Expressive therapists use the different disciplines of the creative arts as therapeutic interventions. This includes the modalities dance therapy, drama therapy, art therapy, music therapy, writing therapy, among others. Expressive therapists believe that often the most effective way of treating a client is through the expression of imagination in creative work and integrating and processing what issues are raised in the act.

Postmodernist

Also known as post-structuralist or constructivist. Narrative therapy gives attention to each person’s “dominant story” by means of therapeutic conversations, which also may involve exploring unhelpful ideas and how they came to prominence. Possible social and cultural influences may be explored if the client deems it helpful. Coherence therapy posits multiple levels of mental constructs that create symptoms as a way to strive for self-protection or self-realization. Feminist therapy does not accept that there is one single or correct way of looking at reality and therefore is considered a postmodernist approach.[81]

Other

Transpersonal psychology addresses the client in the context of a spiritual understanding of consciousness. Positive psychotherapy (PPT) (since 1968) is a method in the field of humanistic and psychodynamic psychotherapy and is based on a positive image of humans, with a health-promoting, resource-oriented and conflict-centered approach.

Hypnotherapy is undertaken while a subject is in a state of hypnosis. Hypnotherapy is often applied in order to modify a subject’s behavior, emotional content, and attitudes, as well as a wide range of conditions including: dysfunctional habits,[82][83][84][85][86] anxiety,[87] stress-related illness,[88][89][90] pain management,[91][92] and personal development.[93][94]

Some non-Western indigenous therapies have been developed. In African countries this includes harmony restoration therapy, meseron therapy and systemic therapies based on the Ubuntu philosophy.[95][96][97]

Child

Counseling and psychotherapy must be adapted to meet the developmental needs of children. It is generally held to be one part of an effective strategy for some purposes and not for others.[99]
In addition to therapy for the child, or even instead of it, children may benefit if their parents speak to a therapist, take parenting classes, attend grief counseling, or take other actions to resolve stressful situations that affect the child. Parent management training is a highly effective form of psychotherapy that teaches parents skills to reduce their child’s behavior problems.

Many counseling preparation programs include courses in human development. Since children often do not have the ability to articulate thoughts and feelings, counselors will use a variety of media such as crayons, paint, clay, puppets, bibliocounseling (books), toys, board games, et cetera. The use of play therapy is often rooted in psychodynamic theory, but other approaches such as Solution Focused Brief Counseling may also employ the use of play in counseling. In many cases the counselor may prefer to work with the care taker of the child, especially if the child is younger than age four. Yet, by doing so, the counselor risks the perpetuation of maladaptive interactive patterns and the adverse effects on development that have already been affected on the child’s end of the relationship.[100] Therefore, contemporary thinking on working with this young age group has leaned towards working with parent and child simultaneously within the interaction, as well as individually as needed.[101][102]

Computer-supported psychotherapy

Research on computer-supported and computer-based interventions has increased significantly over the course of the last two decades.[103][104] The following applications frequently have been investigated:

Virtual reality: VR is a computer-generated scenario that simulates experience. The immersive environment, used for simulated exposure, can be similar to the real world or it can be fantastical, creating a new experience.[106][107]

Computer-based interventions (or online interventions or internet interventions): These interventions can be described as interactive self-help. They usually entail a combination of text, audio or video elements.[108][109]

Computer-supported therapy (or blended therapy): Classical psychotherapy is supported by means of online or software application elements. The feasibility of such interventions has been investigated for individual[110] and group therapy.[111][112]

Effects

Evaluation

One issue with trials is what to use as a placebo treatment group or non-treatment control group. Often, this group includes patients on a waiting list, or those receiving some kind of regular non-specific contact or support. Researchers must consider how best to match the use of inert tablets or sham treatments in placebo-controlled studies in pharmaceutical trials. Several interpretations and differing assumptions and language remain.[114] Another issue is the attempt to standardize and manualize therapies and link them to specific symptoms of diagnostic categories, making them more amenable to research. Some report that this may reduce efficacy or gloss over individual needs. Fonagy and Roth’s opinion is that the benefits of the evidence-based approach outweighs the difficulties.[115]

There are several formal frameworks for evaluating whether a psychotherapist is a good fit for a patient. One example is the Scarsdale Psychotherapy Self-Evaluation (SPSE).[116] However, some scales, such as the SPS, elicit information specific to certain schools of psychotherapy alone (e.g. the superego).

Many psychotherapists believe that the nuances of psychotherapy cannot be captured by questionnaire-style observation, and prefer to rely on their own clinical experiences and conceptual arguments to support the type of treatment they practice. Psychodynamic therapists in particular believe that evidence-based approaches are not appropriate to their methods or assumptions, though some have increasingly accepted the challenge to implement evidence-based approaches in their methods.[117]

Outcomes in relation with selected kinds of treatment

Large-scale international reviews of scientific studies have concluded that psychotherapy is effective for numerous conditions.[3][21]

One line of research consistently finds that supposedly different forms of psychotherapy show similar effectiveness. According to The Handbook of Counseling Psychology: “Meta-analyses of psychotherapy studies have consistently demonstrated that there are no substantial differences in outcomes among treatments”. The handbook states that there is “little evidence to suggest that anyone psychological therapy consistently outperforms any other for any specific psychological disorders. This is sometimes called the Dodo bird verdict after a scene/section in Alice in Wonderland where every competitor in a race was called a winner and is given prizes”.[118]

Further analyses seek to identify the factors that the psychotherapies have in common that seem to account for this, known as common factors theory; for example the quality of the therapeutic relationship, interpretation of problem, and the confrontation of painful emotions.[119][120][121][122]

It should be noted that outcome studies have been critiqued for being too removed from real-world practice in that they use carefully selected therapists who have been extensively trained and monitored, and patients who may be non-representative of typical patients by virtue of strict inclusionary/exclusionary criteria. Such concerns impact the replication of research results and the ability to generalize from them to practicing therapists.[123][124]

However, specific therapies have been tested for use with specific disorders,[125] and regulatory organizations in both the UK and US make recommendations for different conditions.[126][127][128]

The Helsinki Psychotherapy Study was one of several large long-term clinical trials of psychotherapies that have taken place. Anxious and depressed patients in two short-term therapies (solution-focused and brief psychodynamic) improved faster, but five years long-term psychotherapy and psychoanalysis gave greater benefits. Several patient and therapist factors appear to predict suitability for different psychotherapies.[129]

Meta-analyses have established that Cognitive Behavioural Therapy (CBT) and psychodynamic psychotherapy are equally effective in treating depression.[130]

A 2014 meta analysis over 11,000 patients reveals that Interpersonal Psychotherapy (IPT) is of comparable effectiveness to CBT for depression but is inferior to the latter for eating disorders.[131] For children and adolescents, interpersonal psychotherapy and CBT are the best methods according to a 2014 meta analysis of almost 4000 patients.[132]

Mechanisms of change

Different therapeutic approaches may be associated with particular theories about what needs to change in a person for a successful therapeutic outcome.

In general, processes of emotional arousal and memory have long been held to play an important role. One theory combining these aspects proposes that permanent change occurs to the extent that the neuropsychological mechanism of memory reconsolidation is triggered and is able to incorporate new emotional experiences.[133][134][135][136]

Adherence

Patient adherence to a course of psychotherapy—continuing to attend sessions or complete tasks—is a major issue.

The dropout level—early termination—ranges from around 30% to 60%, depending partly on how it is defined. The range is lower for research settings for various reasons, such as the selection of clients and how they are inducted. Early termination is associated on average with various demographic and clinical characteristics of clients, therapists and treatment interactions.[137][138] The high level of dropout has raised some criticism about the relevance and efficacy of psychotherapy.[139]

Most psychologists use between-session tasks in their general therapy work, and cognitive behavioral therapies in particular use and see them as an “active ingredient”. It is not clear how often clients do not complete them, but it is thought to be a pervasive phenomenon.[137]

From the other side, the adherence of therapists to therapy protocols and techniques—known as “treatment integrity” or “fidelity”—has also been studied, with complex mixed results.[140] In general, however, it is a hallmark of evidence-based psychotherapy to use fidelity monitoring as part of therapy outcome trials and ongoing quality assurance in clinical implementation.

Adverse effects

Research on adverse effects of psychotherapy has been limited for various reasons, yet they may be expected to occur in 5% to 20% of patients. Problems include deterioration of symptoms or developing new symptoms, strains in other relationships, and dependency on the therapist. Some techniques or therapists may carry more risks than others, and some client characteristics may make them more vulnerable. Side-effects from properly conducted therapy should be distinguished from harms caused by malpractice.[141]

General critiques

Some critics are skeptical of the healing power of psychotherapeutic relationships.[142][143][144] Some dismiss psychotherapy altogether in the sense of a scientific discipline requiring professional practitioners,[145] instead favoring either nonprofessional help[145] or biomedical treatments.[146] Others have pointed out ways in which the values and techniques of therapists can be harmful as well as helpful to clients (or indirectly to other people in a client’s life).[147][148][149]

Many resources available to a person experiencing emotional distress—the friendly support of friends, peers, family members, clergy contacts, personal reading, healthy exercise, research, and independent coping—all present considerable value. Critics note that humans have been dealing with crises, navigating severe social problems and finding solutions to life problems long before the advent of psychotherapy.[150]

On the other hand, some argue psychotherapy is under-utilized and under-researched by contemporary psychiatry despite offering more promise than stagnant medication development. In 2015, the US National Institute of Mental Health allocated only 5.4% of its budget to new clinical trials of psychotherapies (medication trials are largely funded by pharmaceutical companies), despite plentiful evidence they can work and that patients are more likely to prefer them.[151]

Some Christians, such as theologian Thomas C. Oden, have argued that successful therapeutic relationships, based on true acceptance of the client as a human being without contingency, require a theological assumption, an ontological acceptance of God.[further explanation needed][152][153]

Further critiques have emerged from feminist, constructionist and discourse-analytical sources.[154][155][156] Key to these is the issue of power.[155][157] In this regard there is a concern that clients are persuaded—both inside and outside the consulting room—to understand themselves and their difficulties in ways that are consistent with therapeutic ideas.[143][155] This means that alternative ideas (e.g., feminist,[158] economic,[159] spiritual[160]) are sometimes implicitly undermined.[161] Critics suggest that we idealize the situation when we think of therapy only as a helping relationship—arguing instead that it is fundamentally a political practice, in that some cultural ideas and practices are supported while others are undermined or disqualified, and that while it is seldom intended, the therapist–client relationship always participates in society’s power relations and political dynamics.[143][162][163] A noted academic who espoused this criticism was Michel Foucault.[164][165][166]

^Ethical Principles (2010) of the American Psychological Association, Standard 4: Privacy and Confidentiality online at “Archived copy”. Archived from the original on 1 April 2015. Retrieved 1 April 2015.CS1 maint: Archived copy as title (link).

^Abraham Wolf, Gabor Keitner, & Barbara Jennings, “The Psychotherapeutic Professions in the United States of America” at “Archived copy”(PDF). Archived(PDF) from the original on 2 April 2015. Retrieved 1 April 2015.CS1 maint: Archived copy as title (link).

^Ethical Principles (2010) of the American Psychological Association, online at “Archived copy”. Archived from the original on 1 April 2015. Retrieved 1 April 2015.CS1 maint: Archived copy as title (link).

^Guilfoyle, Michael (February 2005). “From therapeutic power to resistance? Therapy and cultural hegemony”. Theory & Psychology. 15 (1): 101–124. doi:10.1177/0959354305049748. Foucault’s views have been used to highlight problems of power in a variety of ‘mental health’ fields: in nursing (e.g. Clinton & Hazelton, 2002), social work (e.g. Foote & Frank, 1999), psychiatry (e.g. Ali, 2002), and in the cross-disciplinary practices of psychotherapy (most notably in narrative therapy—e.g. Flaskas & Humphreys, 1993; Swann, 1999; White & Epston, 1990). However, there is no single ‘Foucauldian’ approach to power, or indeed to therapy, and his ideas are used, as he intended, more in the manner of a ‘tool kit’ of ideas than as a coherent theoretical account.